Chapter 4 Flashcards
abbreviation
A shortened form of a word
chart
“medical record”
communication
The exchange of information—a message sent is received and correctly interpreted by the intended person
conflict
A clash between opposing interests or ideas
diagnosis
The term used when symptoms, signs, or reasons for a problem are identified
Kardex
A type of card file that summarizes information found in the medical record—medications, treatments, diagnoses, routine care measures, equipment, and special needs
medical record
A written or electronic document of a person’s condition and response to treatment and care; often referred to as a chart or clinical record
prefix
A word element placed before a root; it changes the meaning of the word
progress note
A written description of the care given and the person’s response and progress
recording
The written account of care and observations; charting
reporting
The oral account of care and observations
root
A word element that contains the basic meaning of the word
suffix
A word element placed after a root; it changes the meaning of the word
word element
A part of a word
ADL
Activities of daily living
EHR
Electronic health record
EMR
Electronic medical record
EPHI
Electronic protected health information
HIPAA
Health Insurance Portability and Accountability Act
MDS
Minimum data set
OBRA
Omnibus Budget Reconciliation Act of 1987
PHI
Protected health information
POC
Point of care
